cswork / libraryOpen practice workspace

Interview guides · Astrana Health

Astrana Health Software Engineer Interview Guide

Astrana Health Software Engineer interview guide: reported rounds, questions and how candidates describe the process.

The 60-second brief

As a Software Engineer (often holding the internal title of Forward Deployed Engineer) at Astrana Health, you are at the forefront of transforming value-based healthcare delivery. Your work directly bridges the gap between complex health data systems and the end-users who rely on them daily. This role is not just about writing code; it is about building robust, highly available platforms that serve diverse user bases, including patients, medical providers, and administrative staff. The impact of this position is immense. You will be responsible for architecting and scaling critical infrastructure, such as comprehensive booking portals and care management systems. Because Astrana Health operates at the intersection of technology and patient care, the systems you build must balance strict compliance and high availability with intuitive usability.

This guide is scoped to a Software Engineer candidate at Astrana Health.

Focus areas

  • Systems Design
  • Scalability
  • High Availability

The Astrana Health interview process

Astrana Health candidates report 4 rounds over 3-5 weeks. The stages below are what candidates describe, not a published process.

HR Screen

Initial conversation to align on expectations, background, and logistics.

What to demonstrate

  • Initial conversation to align on expectations, background, and logistics
  • Depth in Systems Design

How to prepare

  • Be able to walk your CV end to end in two minutes, and say why this company specifically.
  • Have your salary expectations, notice period and location constraints ready, and ask for the rest of the loop in writing.

Executive Culture Fit

Low-stakes discussion with a VP of Engineering focused on company direction and mutual fit.

What to demonstrate

  • Low-stakes discussion with a VP of Engineering focused on company direction and mutual fit
  • Depth in Systems Design

How to prepare

  • Prepare three examples from your own work, each with a decision you made and an outcome you can quantify.
  • Re-read the description of the executive culture fit above and write down what you would ask to confirm before it.

Technical Core Interview

Deep technical rounds focusing on system design and architecture, often led by a Director of Engineering.

What to demonstrate

  • Deep technical rounds focusing on system design and architecture, often led by a Director of Engineering
  • Depth in Systems Design

How to prepare

  • Answer aloud and timed: Describe how you would build a notification system to alert patients and doctors of schedule changes.
  • Answer aloud and timed: Design the database schema for a multi-tenant healthcare scheduling application.

Software Leads Interview

Final stages involving various software leads to assess coding practices and problem-solving skills.

What to demonstrate

  • Final stages involving various software leads to assess coding practices and problem-solving skills
  • Depth in Systems Design

How to prepare

  • Answer aloud and timed: What table structures would you use to represent a doctor's weekly availability, exceptions, and booked appointments?
  • Answer aloud and timed: Explain the tradeoffs between different database indexing strategies for a read-heavy patient dashboard.

Where candidates lose points

Know Your Personas

Always frame your technical decisions around the end-user. When discussing a feature, explicitly state how it impacts the patient experience versus the doctor's workflow. Demonstrating empathy for these distinct groups will set you apart.

Master Data Modeling

Be ready to transition smoothly from drawing high-level architecture boxes to writing out exact database schemas. You must be able to defend your primary keys, foreign keys, and indexing strategies confidently.

Check-then-act on shared state

Read, decide, write is not safe under concurrency unless the decision and the write are one atomic step: a unique constraint with conflict handling, a compare-and-set, or a row lock held for the whole transaction. Two requests can both pass the existence check before either inserts, which shows up as duplicate rows under load and never in a single-threaded test.

Questions & practice

Diff a projection against the primary without per-row point reads

Hard · reconciliation · range hashing · throttling

The listing projection has drifted and some rows show a stale version. The primary holds 40,000,000 resource rows across 12,000 tenants while serving 1,200 writes and 14,000 reads per second. The obvious repair, reading each resource row and comparing its version against the projection, is correct and would eventually finish. Explain precisely why it is unacceptable here, then give a diff that finds the differing rows, state its complexity, and make it safe to run against a live primary. Replication lag is usually under 100 ms and is not bounded.

Approach

  1. Quantify the naive cost rather than calling it slow: 40,000,000 point reads at even 0.5 ms each is over five hours serialised, and the only lever is concurrency, which is exactly what you cannot spend. The primary's pool is sized for the write path, and 40,000,000 random reads evict the buffer cache that sustains the 85 percent cache hit rate, so the audit degrades the system it is auditing.
  2. Replace random access with one ordered pass per side. Both sides can be read in (tenant_id, resource_id) order, which is a sequential scan on each and a merge join in O(n) time and O(1) memory. For a dense diff that is the whole answer, and it reads the primary once instead of 40,000,000 times.
  3. For the expected sparse case, compare range hashes instead of rows: partition the key space, compute per range an order-independent aggregate over hash(resource_id, version), compare aggregates, and descend only into ranges that differ. With d differing rows and branching factor B, at most d ranges mismatch per level, so the drill-down examines O(d log_B(n/d)) ranges and reads full rows only in mismatching leaves.
  4. Aggregate with a sum modulo 2^64 or a multiset hash, never XOR. XOR is order-independent but self-cancelling, so two rows wrong in the same way, or a row duplicated on one side, leave the range aggregate matching and the range is declared clean.

Follow-up

  • The diff reports 900 stale rows. How do you decide between patching those rows and rebuilding the projection from resource_revision?
  • Same job, but the projection lives in a search index that cannot be scanned in key order. What changes?

Canonicalise a request body into a stable idempotency fingerprint

Medium · parsing · canonicalisation · hashing

idempotency_key.request_fingerprint is a SHA-256 over the method, path and canonicalised body, and a retry whose fingerprint differs must be rejected with 422 rather than served the stored response. Write the canonicaliser. Bodies are JSON up to 256 KB nested at most 32 levels; clients vary key order, whitespace and unicode escaping, and some send 64-bit ids as JSON numbers. Produce a deterministic byte string such that semantically identical bodies match and any semantic difference does not. State your complexity and name two normalisations you refuse to perform.

Approach

  1. Parse once into a tree, then re-serialise under fixed rules: object keys sorted, array order preserved, one escaping convention, no insignificant whitespace. Parsing is O(n) and sorting keys is O(k log k) per object, so O(n log n) overall with O(depth) stack, and the 32-level cap is enforced during parsing because hostile nesting is how a canonicaliser becomes a stack overflow.
  2. Sort keys by their UTF-8 bytes and say why the obvious implementation is wrong in some runtimes: a default string comparison that orders by UTF-16 code units places surrogate pairs, meaning code points from U+10000 up, below U+E000 to U+FFFF, which is not UTF-8 byte order, so two services written in different languages disagree on the same document.
  3. Do not re-encode numbers through a double. IEEE-754 binary64 represents integers exactly only up to 2^53, so normalising a 19-digit id through a float changes it, and 1 against 1.0 cannot be reconciled without deciding whether they are the same value. Preserve the literal token, and require ids as strings at the API boundary if you want them comparable.
  4. Reject duplicate keys rather than picking one. JSON permits them and parsers disagree, most keeping the last, so any choice you make ties the fingerprint to a parser detail that the code handling the request does not necessarily share.

Follow-up

  • A client sends the same logical request with an extra field your API ignores. Same key, different fingerprint, so you return 422. Is that the right answer?
  • Where does the fingerprint get computed relative to request decompression and the body-size limit?

Track a rolling failure rate per destination for circuit decisions

Easy · sliding window · ring buffer · circuit breaker

The egress service delivers about 1,500 webhooks per second across roughly 40,000 destinations, each call bounded by a 10 second timeout. Maintain, per destination, the failure rate over the trailing 60 seconds so a caller can ask before dispatch whether the circuit should open. Attempts arrive as (destination_id, finished_at_ms, outcome). Requirement: amortised O(1) per attempt, with total memory bounded by the destination count rather than by traffic. Give the structure, its exact memory, and the rule that stops a destination with three attempts from opening a circuit.

Approach

  1. Name the exact-deque version and then reject it as the default. Holding timestamps and advancing a tail pointer past anything older than now minus 60 seconds is a correct two-pointer window at amortised O(1) per attempt, but its memory tracks in-window traffic, so one destination in a retry storm holds hundreds of thousands of entries while thousands of quiet destinations hold none.
  2. Use a ring of 60 one-second buckets per destination, each bucket a pair of counters for attempts and failures. On an attempt, advance the ring by the elapsed whole seconds, zeroing at most min(elapsed, 60) buckets, then increment the head. That is amortised O(1) with a fixed footprint per destination.
  3. State the footprint: 60 buckets times two 4-byte counters is 480 bytes of payload per destination, so 40,000 destinations is roughly 20 to 25 MB with per-entry overhead, bounded by the catalogue rather than by the rate. The cost is granularity, since the oldest bucket ages out in whole seconds, which is far tighter than the decision needs.
  4. Require a minimum sample before the circuit may open. A destination with three attempts and three failures reads as 100 percent and is not evidence; a floor of roughly 20 attempts in the window makes the ratio meaningful, and below that floor use a run of consecutive failures as the trigger instead.

Follow-up

  • The fleet is 30 instances and each sees roughly a thirtieth of a destination's traffic. Where does the rate actually live, and what does a per-instance answer get wrong?
  • A destination answers in 9.5 seconds and succeeds. It is not failing but it is consuming your per-destination concurrency. What signal should open the circuit here?

Design the database schema for a multi-tenant healthcare scheduling application.

Medium · Data Modeling & Database Design

Approach

  1. Name the grain you start from and join outward from it.
  2. Check whether any join is one-to-many before aggregating, or the sums inflate.
  3. Say which index the query would use, and what makes it unusable.
  4. Handle the rows that do not match: that is usually the actual question.

Follow-up

  • How does the query change if that join becomes one-to-many?
  • What happens to this when the table is ten times larger?

Replace offset paging on the resource feed with keyset

Easy · keyset pagination · composite index · sort order

resource holds resource_id, tenant_id, owner_user_id, title, body_ref, version, status ('draft','active','archived','deleted'), created_at, updated_at, deleted_at, with an index on (tenant_id, status, updated_at DESC, resource_id DESC). The listing endpoint returns active resources for one tenant, newest update first, 50 per page, today with LIMIT 50 OFFSET n. Tenants reach page 400 and rows are created while they read. Write the keyset query, define what the cursor carries and how it is encoded, and say which part of the index each predicate uses. Assume PostgreSQL 16.

Approach

  1. Name the two failures separately. OFFSET 20000 makes the server produce and discard 20,000 rows, so page cost grows with depth rather than with page size. Independently, any write that changes how many rows sort above the offset moves the window between two fetches, and the direction decides which anomaly you get: an insert lands at the head of updated_at DESC and pushes already-returned rows down past the boundary, so they are returned a second time; a delete above the offset, or a row whose updated_at is bumped above the cursor, pulls rows up and one is never returned at all. Nothing in the response reveals either.
  2. Write the seek: WHERE tenant_id = $1 AND status = 'active' AND (updated_at, resource_id) < ($2, $3) ORDER BY updated_at DESC, resource_id DESC LIMIT 50. The row-value comparison is one index range rather than a disjunction, and both columns are NOT NULL, which is what makes that comparison well defined.
  3. Map each predicate onto the index: tenant_id and status are equality on the leading columns, (updated_at, resource_id) is the range, and the ORDER BY matches the index order so no Sort node appears and the scan stops after 50 rows. The DESC in the definition only matters for mixed directions — a plain ascending btree on the same columns is read backwards for this query.
  4. Put both sort columns in the cursor and nothing the client can tamper with into another tenant: base64 of (updated_at, resource_id), validated server-side, with tenant_id taken from the principal.

Follow-up

  • The client asks for 'jump to page 400'. What do you offer instead, and what does the honest version cost?
  • Sort order becomes user-selectable across four columns. How many indexes is that, and which would you refuse to add?

Design a comprehensive booking portal for patients, doctors, and medical admins.

Medium · System Design & Architecture

Approach

  1. Fix the scope first: who calls this, how often, and what they do when it fails.
  2. Name the read and write paths separately; they rarely have the same bottleneck.
  3. Choose a partition key and say what query it makes expensive.
  4. State the consistency you need, and where you are willing to be stale.

Follow-up

  • What breaks first when traffic grows ten times?
  • How does this behave when that dependency is down for an hour?

How would you architect a highly available system that handles sudden spikes in traffic during open enrollment

Medium · System Design & Architecture

How would you architect a highly available system that handles sudden spikes in traffic during open enrollment periods?

Approach

  1. Fix the scope first: who calls this, how often, and what they do when it fails.
  2. Name the read and write paths separately; they rarely have the same bottleneck.
  3. Choose a partition key and say what query it makes expensive.
  4. State the consistency you need, and where you are willing to be stale.

Follow-up

  • What breaks first when traffic grows ten times?
  • How does this behave when that dependency is down for an hour?

Walk me through the scaling components you would implement for a healthcare platform on day one.

Medium · System Design & Architecture

Approach

  1. Fix the scope first: who calls this, how often, and what they do when it fails.
  2. Name the read and write paths separately; they rarely have the same bottleneck.
  3. Choose a partition key and say what query it makes expensive.
  4. State the consistency you need, and where you are willing to be stale.

Follow-up

  • What breaks first when traffic grows ten times?
  • How does this behave when that dependency is down for an hour?

How do you design a system to ensure that no two patients can book the same doctor's appointment slot simultan

Medium · System Design & Architecture

How do you design a system to ensure that no two patients can book the same doctor's appointment slot simultaneously?

Approach

  1. Fix the scope first: who calls this, how often, and what they do when it fails.
  2. Name the read and write paths separately; they rarely have the same bottleneck.
  3. Choose a partition key and say what query it makes expensive.
  4. State the consistency you need, and where you are willing to be stale.

Follow-up

  • What breaks first when traffic grows ten times?
  • How does this behave when that dependency is down for an hour?

Describe how you would build a notification system to alert patients and doctors of schedule changes.

Medium · System Design & Architecture

Approach

  1. Fix the scope first: who calls this, how often, and what they do when it fails.
  2. Name the read and write paths separately; they rarely have the same bottleneck.
  3. Choose a partition key and say what query it makes expensive.
  4. State the consistency you need, and where you are willing to be stale.

Follow-up

  • What breaks first when traffic grows ten times?
  • How does this behave when that dependency is down for an hour?

What table structures would you use to represent a doctor's weekly availability, exceptions, and booked appoin

Medium · Data Modeling & Database Design

What table structures would you use to represent a doctor's weekly availability, exceptions, and booked appointments?

Approach

  1. Clarify what is being asked and what a complete answer contains.
  2. State your assumptions explicitly before working the problem.
  3. Say what you would check first and why it is the highest-information step.
  4. Work from the requirement backwards to the design.

Follow-up

  • What assumption would you test first?
  • How would you know your answer was wrong?

Explain the tradeoffs between different database indexing strategies for a read-heavy patient dashboard.

Medium · Data Modeling & Database Design

Approach

  1. Clarify what is being asked and what a complete answer contains.
  2. State your assumptions explicitly before working the problem.
  3. Say what you would check first and why it is the highest-information step.
  4. Work from the requirement backwards to the design.

Follow-up

  • What assumption would you test first?
  • How would you know your answer was wrong?

How would you structure your database to handle complex permissions for hospital administrators?

Medium · Data Modeling & Database Design

Approach

  1. Clarify what is being asked and what a complete answer contains.
  2. State your assumptions explicitly before working the problem.
  3. Say what you would check first and why it is the highest-information step.
  4. Work from the requirement backwards to the design.

Follow-up

  • What assumption would you test first?
  • How would you know your answer was wrong?

Walk me through how you would migrate a legacy patient database to a new schema with zero downtime.

Medium · Data Modeling & Database Design

Approach

  1. Clarify what is being asked and what a complete answer contains.
  2. State your assumptions explicitly before working the problem.
  3. Say what you would check first and why it is the highest-information step.
  4. Work from the requirement backwards to the design.

Follow-up

  • What assumption would you test first?
  • How would you know your answer was wrong?

p99 jumped on one listing filter while p50 stayed flat

Medium · query planning · composite index · percentiles

After a release that added an owner_user_id filter to the resource listing, p99 rose from 90 ms to 1.9 s while p50 stayed at 40 ms. Traffic and row counts are unchanged. resource carries the index (tenant_id, status, updated_at DESC, resource_id DESC). The new query filters tenant_id and owner_user_id, orders by updated_at DESC, resource_id DESC, and takes 20 rows. On PostgreSQL, explain the shape of the regression, prove it from a query plan, and give the index you would add.

Approach

  1. Start from the shape. A flat p50 with a moved p99 means a subset of requests changed cost, not all of them, so the first job is naming the subset. Bucket the endpoint's latency by the tenant's row count; the natural hypothesis is that large tenants are a small share of requests and all of the tail.
  2. Get the plan for the new query on a large tenant with EXPLAIN (ANALYZE, BUFFERS). Expect an index scan over the tenant's range, a filter discarding most of it, then a Sort feeding the Limit, possibly reporting Sort Method: external merge Disk. Read actual rows on the scan node, not estimated.
  3. Explain why the existing index cannot serve it. A composite B-tree is seekable only as a left prefix, and with no equality predicate on status the scan cannot treat updated_at as an ordering, because rows in the tenant's range are ordered by status first. Everything matching must be read and sorted before LIMIT 20 can apply, so a tenant with 400,000 rows pays 400,000 rows to return 20.
  4. Add (tenant_id, owner_user_id, updated_at DESC, resource_id DESC). Equality on the first two columns leaves the index ordered by updated_at within that pair, so the plan becomes an index scan that stops after 20 rows with no Sort node. PostgreSQL can scan a B-tree backwards, so the DESC markers matter only if the two sort columns ever disagree in direction; keeping them explicit documents the order the keyset cursor depends on.

Follow-up

  • The endpoint paginates with OFFSET. What does page 500 cost with your index, and what does the keyset version cost?
  • How would you have caught this before release, given that a 10,000-row seed database produces the same plan shape at an unnoticeable cost?

Suggested practice checklist

Built from the rounds and topics Astrana Health candidates report.

Day 1 — Map the Astrana Health loop

  • Write out the reported sequence: HR Screen, Executive Culture Fit, Technical Core Interview, Software Leads Interview.
  • For each round, write one sentence on what it is judging, from the description above, and mark the one you are least ready for.

Deliverable: A one-page map of the 4 reported rounds, with the weakest marked.

Day 2 — Work Systems Design

  • Spend the session on Systems Design, which Astrana Health candidates report being tested on.
  • Write one worked example in Systems Design and time yourself on it.

Deliverable: One timed worked example in Systems Design.

Day 3 — Work Scalability

  • Spend the session on Scalability, which Astrana Health candidates report being tested on.
  • Write one worked example in Scalability and time yourself on it.

Deliverable: One timed worked example in Scalability.

Day 4 — Work High Availability

  • Spend the session on High Availability, which Astrana Health candidates report being tested on.
  • Write one worked example in High Availability and time yourself on it.

Deliverable: One timed worked example in High Availability.

Day 5 — Answer out loud: System Design & Architecture

  • Answer aloud, timed: Design a comprehensive booking portal for patients, doctors, and medical admins.
  • Answer aloud, timed: How would you architect a highly available system that handles sudden spikes in traffic during open enrollment periods?

Deliverable: Spoken answers to 2 reported System Design & Architecture question(s), under time.

Day 6 — Answer out loud: Data Modeling & Database Design

  • Answer aloud, timed: Design the database schema for a multi-tenant healthcare scheduling application.
  • Answer aloud, timed: What table structures would you use to represent a doctor's weekly availability, exceptions, and booked appointments?

Deliverable: Spoken answers to 2 reported Data Modeling & Database Design question(s), under time.

Day 7 — Answer out loud: Behavioral & Leadership

  • Answer aloud, timed: Tell me about a time you received critical feedback on a system design. How did you handle it?
  • Answer aloud, timed: Describe a situation where you had to balance the competing needs of two different user groups in your software.

Deliverable: Spoken answers to 2 reported Behavioral & Leadership question(s), under time.

Behavioural preparation

Behavioural rounds judge the decision you made and what it cost.

Tell me about a time you received critical feedback on a system design. How did you handle it?

Medium · Behavioral & Leadership

Approach

  1. Pick a story where you made the decision, not one where you watched it.
  2. State the situation in two sentences and spend the rest on the reasoning.
  3. Give the blast radius: what could have broken, and what you measured.
  4. Name the disagreement and how you resolved it with evidence.

Follow-up

  • What would you do differently if you ran that again?
  • How did you know your change caused the improvement?

Describe a situation where you had to balance the competing needs of two different user groups in your softwar

Medium · Behavioral & Leadership

Describe a situation where you had to balance the competing needs of two different user groups in your software.

Approach

  1. Pick a story where you made the decision, not one where you watched it.
  2. State the situation in two sentences and spend the rest on the reasoning.
  3. Give the blast radius: what could have broken, and what you measured.
  4. Name the disagreement and how you resolved it with evidence.

Follow-up

  • What would you do differently if you ran that again?
  • How did you know your change caused the improvement?

How do you ensure your engineering work aligns with the broader business goals of your company?

Medium · Behavioral & Leadership

Approach

  1. Pick a story where you made the decision, not one where you watched it.
  2. State the situation in two sentences and spend the rest on the reasoning.
  3. Give the blast radius: what could have broken, and what you measured.
  4. Name the disagreement and how you resolved it with evidence.

Follow-up

  • What would you do differently if you ran that again?
  • How did you know your change caused the improvement?

Tell me about a time you proactively identified a scalability issue and fixed it before it became a problem.

Medium · Behavioral & Leadership

Approach

  1. Pick a story where you made the decision, not one where you watched it.
  2. State the situation in two sentences and spend the rest on the reasoning.
  3. Give the blast radius: what could have broken, and what you measured.
  4. Name the disagreement and how you resolved it with evidence.

Follow-up

  • What would you do differently if you ran that again?
  • How did you know your change caused the improvement?

Why are you interested in building software for the healthcare space?

Medium · Behavioral & Leadership

Approach

  1. Pick a story where you made the decision, not one where you watched it.
  2. State the situation in two sentences and spend the rest on the reasoning.
  3. Give the blast radius: what could have broken, and what you measured.
  4. Name the disagreement and how you resolved it with evidence.

Follow-up

  • What would you do differently if you ran that again?
  • How did you know your change caused the improvement?