I know you are asking for experience or how to get it but I wanted to give you the whole overview.
If you want hospital or even insurance Utilization review again like so many other have informed... just apply. I do know the Blues and Ameriben is hiring and you can work from home. I started with no experience in insurance and thought insurance companies were big and bad.
Your duties will be to review clinical documentation and compare to evidence based industry standards. An example would be if a patient has Crohns disease and the request is for Remicade. You would review what the patient has tried, what works , not work, weight-really get a summary of your patient history and current status. You then use policies/industry standards (this includes the Remicade FDA full prescribing sheet). If it meets the criteria/policy guidelines form Insurance then you approve, if not then you ask for additional information or send to the Medical Director for review. Please note you are expected to complete/review a set number of cases per day, I think the average is 20-30 cases. If you do not have the information then you request the information.
Some cases get complicated, some are quick approval and some well you just scratch your head and think wow this is my medical profession. As a whole I love UR/CM, I feel I can go back into direct patient cares as I volunteer at a red cross center so I keep my clinical skills up-to-date. I have work everything from Chemotherapy, transplants to Rheumatology to Gastroparesis...and all in-between.
A lot of misconception when going to work for an insurance company, I had them. Thought the insurance company kept monies they deny, practiced of denial until you just went away...told the providers what to do...these are myths. Insurance companies only manage what the company you work or spouses work for has decided for your health benefits. We approve way more than we deny so it is in the provider best interest to know the criteria for what they are asking for and submit supporting documentation based on that criteria, I tell them this all the time-transparency.
Insurance companies do not tell providers what they can and cannot prescribed or what procedures they may provide. An example is IV Iron Infusions and the place of service. Injectafer is the most expensive of the IV iron medication and a great deal of providers ask for this medication, they send in Labs and ask for this IV in an outpatient hospital. There are other IV Iron infusions that produce similar results and are more cost effective i.e. Fereheme or Venofer come to mind (the cost difference can be as high as 2000.00 per infusion). I want to know why Injectafer was picked instead of a more cost effective medication and why this needs to be completed in a hospital verses a infusion suite like say from Option Care/Walgreens (not corner of happy healthy but a true infusion suite that has experience RN staff on site, has crash carts and pharmacists). When the provider submits supporting documentation I am looking for issues such as patient had past IV infusion with SOB, bad stick frail veins-prior addict, passed out...rash all over body...I will gladly approve in outpatient hospital but if I do not get that kind of documentation then I send to a medical advisor who will then determine (usually a partial approval for IV iron) the provider still has to pick which IV iron (other than Injectafer) and denial for place of service in out patient hospital.
When I write the partial approval/denial it goes something like this: Allow IV Venofer infusions not greater than 200 mg and not more than 3 infusions to be administered in a non-hospital infusion suite as medical necessary per policy 123456, and Denial of place of service in a hospital outpatient setting per policy 12345. This verbiage is inserted into an insurance letter that goes out to the patient and provider.
This is just a small example of how my days go when it comes to reviewing for medical necessity.
Good luck to you and hopefully the start of a new career.