Intermountain Health Software Engineer Interview Guide

The 60-second brief

As a Software Engineer at Intermountain Health, you serve as a critical bridge between complex healthcare data and the clinical outcomes that define our mission. You are not just writing code; you are building the digital infrastructure that empowers caregivers, improves patient experiences, and streamlines the operational efficiency of one of the nation’s most respected non-profit health systems. Whether you are working on internal clinical applications, patient-facing portals, or backend integrations, your work directly impacts the speed and quality of care delivered across our facilities. The environment at Intermountain Health is uniquely collaborative and mission-driven. You will find yourself working alongside cross-functional teams that include product managers, clinicians, and system architects.

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

Focus areas

• C#
• .NET /.NET Fiddle
• Programming problem solving / coding exercises

The Intermountain Health interview process

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

Initial Screening Call

A call with a recruiter to evaluate your background and fit for the role.

What to demonstrate

• A call with a recruiter to evaluate your background and fit for the role
• Depth in C#

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.

Technical Rounds

One or more interviews that may include panel interviews, live coding sessions, or discussions about past projects.

What to demonstrate

• One or more interviews that may include panel interviews, live coding sessions, or discussions about past projects
• Depth in C#

How to prepare

• Answer aloud and timed: What is your experience with C#, SQL, and JavaScript in a production environment?
• Answer aloud and timed: How do you handle edge cases when building a new function or service?

Final Panel Interview

A concluding interview where you meet the team members you will work with daily.

What to demonstrate

• A concluding interview where you meet the team members you will work with daily
• Depth in C#

How to prepare

• Answer aloud and timed: Describe a time you had to debug a complex technical issue under pressure.
• Answer aloud and timed: Tell us about a time you had to overcome a significant difficulty while working on a project.

Where candidates lose points

Prepare for the "Why

Be ready to articulate why you want to work for a healthcare organization specifically. Aligning your personal values with our mission of providing excellent care goes a long way.

Practice the STAR Method

When answering behavioral questions, use the Situation, Task, Action, Result format to keep your responses structured and concise.

Bring Questions

Use the time at the end of the interview to ask about the team’s current challenges or the company’s vision. This shows you are engaged and thinking beyond just the interview itself.

Be Honest About Your Skills

If you don't know the answer to a technical question, it is better to explain how you would find the answer than to guess. We value honesty and the ability to learn.

Questions & practice

Can you explain your process for converting an integer to a Roman numeral and vice-versa?

Medium · Technical and Problem Solving

Approach

1. Restate the input: its shape, its size, and what is guaranteed about it.
2. Name the brute-force solution and its complexity before improving on it.
3. Choose the data structure from the access pattern, not from familiarity.
4. State the target complexity and say which constraint rules the naive version out.

Follow-up

• How does this change if the input no longer fits in memory?
• What is the worst case, and how likely is it on real data?

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?

Find overlapping job attempts and peak concurrency from lease records

Medium · sweep line · intervals · leases

A day of job_run history yields about 50,000,000 attempt records: (job_run_id, job_type, attempt, started_at, finished_at which is NULL when the worker died, lease_expires_at). Leases expire on a clock, so a job that outran its lease ran twice. Produce (a) every job_run_id whose attempts overlapped in wall-clock time and (b) the peak number of simultaneously running attempts per job_type with the minute it occurred. Target O(n log n). State how you treat a NULL finished_at and what clock skew does to your answer.

Approach

1. Define the interval before sorting anything: an attempt occupies [started_at, COALESCE(finished_at, lease_expires_at)). finished_at is observed and lease_expires_at is only a promise, so every attempt without a finish contributes an estimate and the whole result is a lower bound on overlap rather than an exact count.
2. For peak concurrency, sweep: emit 2n endpoints, sort by (timestamp, kind) with ends ordered before starts at equal timestamps, then walk the sequence maintaining a counter per job_type and record each type's maximum with its timestamp. O(n log n) dominated by the sort, O(n) space, or O(1) extra if the sort is external and the walk streams.
3. For overlap detection, do not compare attempts pairwise. A single global sort by (job_run_id, started_at) gives both the grouping and the order; within a group, keep the maximum end seen so far and report an overlap exactly when the next start is less than that running maximum, which is one linear pass after the sort.
4. Half-open intervals matter and are easy to get wrong: with closed intervals an attempt ending at the same millisecond another begins reads as concurrency two, and across 50,000,000 records that artefact swamps the real signal.

Follow-up

• A handler is not idempotent and you have found 400 overlapping jobs. Which of them actually caused damage, and what would you query to find out?
• Peak concurrency for one job_type is 4 against a configured cap of 4. Is the cap working, or is the data hiding attempts that never started?

Hold a per-tenant active cap against concurrent creates

Hard · write skew · isolation levels · constraints

A tenant on the standard plan may hold at most 50 resources with status='active'. The create handler runs SELECT count(*) FROM resource WHERE tenant_id = $1 AND status = 'active', compares to 50, then inserts. Two creates arrive 3 ms apart on different instances and the tenant lands at 51. Name the anomaly, say whether PostgreSQL 16 READ COMMITTED or REPEATABLE READ prevents it and why, then give an implementation that holds the cap at READ COMMITTED with the exact statements. Finally, say what changes when the cap is 'at most one running export per tenant' on job_run.

Approach

1. Name it: write skew. The two transactions read an overlapping set and write disjoint rows, so there is no row-level conflict for the engine to detect and each commit is individually legal.
2. Rule out the levels precisely. READ COMMITTED takes a fresh snapshot per statement and takes no lock on the counted rows, so both see 49. PostgreSQL's REPEATABLE READ is snapshot isolation: it removes non-repeatable reads and phantoms within the snapshot but still admits write skew, because the anomaly is not a re-read of a changed row, it is a read of a set that a concurrent transaction invalidates. Only SERIALIZABLE closes it, by tracking the read dependency and aborting one transaction with SQLSTATE 40001 — a guarantee that exists only if the application re-runs the whole transaction from the read.
3. Convert the set predicate into a single-row conflict: keep tenant.active_resource_count and run UPDATE tenant SET active_resource_count = active_resource_count + 1 WHERE tenant_id = $1 AND active_resource_count < 50 in the same transaction as the INSERT. Zero affected rows is the cap, returned as 409. The row lock serialises the decision at any isolation level, and contention is bounded to one tenant's row — which is also the fair-scheduling unit, unlike a global counter that would convoy every tenant behind one row.
4. State the cost you just took on: a counter is a second source of truth that can drift, so every path that changes status must adjust it inside the same transaction, and a periodic reconciliation has to exist, with resource_revision as the authority for what the count should have been.

Follow-up

• A resource moves from archived back to active. Which statements change, and what breaks if the counter update and the status change land in different transactions?
• The cap becomes plan-dependent and a plan can change mid-month. Where does the number 50 live, and who reads it?

Stop tag and share joins from fanning out a page

Medium · join fan-out · semi-joins · many-to-many

resource_tag is (resource_id, tag_id) with PK (resource_id, tag_id); resource_share is (resource_id, shared_with_user_id, permission). The tagged-and-shared listing inner-joins resource to both, filters tenant_id, tag_id = ANY($2) and shared_with_user_id = $3, orders by updated_at DESC and takes 50. Pages come back with fewer than 50 distinct resources and the total in the header is far too high. Explain the row multiplication, rewrite both the page query and the count query so each is correct, and name the index each one needs. PostgreSQL 16.

Approach

1. Do the arithmetic against the predicates that are actually there. An inner join emits one row per matching child row, and both joins are filtered: tag_id = ANY($2) admits only the requested tags, shared_with_user_id = $3 admits one user's share rows. So a resource holding three of the requested tags and shared with $3 once yields three rows, not one — the multiplier is its count of matching tags times its share rows for that single user, and that second factor is 1 unless the table admits duplicate (resource_id, shared_with_user_id) pairs. LIMIT 50 then limits rows rather than resources, and COUNT(*) counts pairs — the header is the product, not the population.
2. Reject DISTINCT as the fix. It deduplicates after the product has been built, so the planner must materialise and sort the fanned-out set before the LIMIT can apply, and it leaves any SUM or AVG in the same select list wrong.
3. Rewrite both filters as semi-joins, keeping resource as the only row source: AND EXISTS (SELECT 1 FROM resource_tag rt WHERE rt.resource_id = r.resource_id AND rt.tag_id = ANY($2)) and the same shape against resource_share. A semi-join stops at the first match per resource and preserves the driving index order, so ORDER BY updated_at DESC, resource_id DESC LIMIT 50 still stops after 50 rows.
4. Count with the same predicates and no join at all: SELECT count(*) FROM resource r WHERE r.tenant_id = $1 AND r.status = 'active' AND EXISTS (...) AND EXISTS (...). Nothing multiplies a resource, so the number is the population.

Follow-up

• The filter changes from 'any of these tags' to 'all of these tags'. Rewrite it and state what it costs relative to the ANY form.
• A resource can be shared with the same user twice under different permissions. Does your count change, and should it?

Choose what to break when replication lag reaches forty seconds

Hard · replication lag · read-after-write · consistency vs availability

Reads are served from two replicas: 14k requests/second, about 85% absorbed by cache, so roughly 2.1k reads/second reach the database. Writes go to the primary at 1.2k/second. A tenant's backfill drives replication lag from under 100 ms to 40 seconds and it is still climbing. Sessions that have just written are pinned to the primary. Decide, endpoint class by endpoint class, whether to serve stale, fail, or route to the primary, and justify each choice with the load it adds to the primary. Then state what you would have built beforehand.

Approach

1. Establish blast radius before cause, because mitigation and diagnosis have different deadlines. The decisive arithmetic is what happens if the database reads move to the primary: 2.1k reads/second on top of 1.2k writes/second roughly triples its operation count, on the node already absorbing the backfill that caused this. Reads and writes are not equal in cost, so treat that as an argument against a blanket move rather than as a capacity model - but it is enough to rule out routing everything to the primary.
2. Classify endpoints by what staleness costs, not by how important they feel. Reads whose staleness is invisible - listings, search, counters - stay on the replica and return the watermark so the client can tell. Reads that immediately follow that same session's write keep their primary pin, which is a small bounded slice of traffic rather than the whole 2.1k/second. Reads that feed a decision with a side effect - authorisation, quota, the read half of a read-modify-write - must not be stale at all, because a 40-second-old permission row is the stale-permission failure wearing a different costume; those go to the primary or fail.
3. Shed instead of queueing. If the must-be-fresh class alone exceeds the primary's headroom, refuse its lowest-value slice with 503 and a retry-after. A request queued behind a saturated primary holds a connection for a client that has already given up, and the retry storm that follows is what turns degradation into an outage. Bound the connection pool per role so the read fallback cannot consume the write path's connections - that bulkhead is the single decision that determines whether writes survive the next ten minutes.
4. Attack the cause in parallel, since it is the one thing that can be stopped. The backfill is the load generator. A backfill that reads replication lag as its throttle signal and pauses above a threshold would have made this a non-event, with batch sizes small enough that each batch's write volume is a fraction of what a replica can apply per second. That is most of the answer to what should have existed beforehand.

Follow-up

• Lag returns to normal in nine minutes. Which mitigation do you remove first, and which one stays permanently?
• A user reports their change did not save, and the write committed. Trace the path that produces that report and name the signal that would have shown it before the report arrived.

Relay committed events to the log without gaps or reordering

Medium · transactional outbox · at-least-once · ordering

outbox_event rows are written in the same transaction as the state change and carry aggregate_type, aggregate_id, aggregate_version, payload and status, with a partial index on (created_at, event_id) WHERE status = 'pending'. The relay publishes about 4k events/second to a partitioned append-only log keyed by aggregate_id, with one leader per partition range holding a lease. Consumers must never miss an event; they may see one twice. Design the claim-publish-mark loop, and state exactly what consumers observe when a leader's lease expires while it is mid-batch.

Approach

1. Claim with SELECT ... WHERE status='pending' ORDER BY created_at, event_id LIMIT $batch FOR UPDATE SKIP LOCKED inside a transaction. SKIP LOCKED lets several relay workers share a range without serialising on each other's rows, and the partial index keeps the claim proportional to the backlog rather than to a table that is overwhelmingly published rows. At 4k/second a batch of 500 is eight claims per second, each an index scan of 500 entries.
2. Publish before marking, never the reverse, and say why it is a choice. Marking first loses the event outright if the process dies in the gap, and the loss is silent - nothing remains to retry, and it surfaces later as a projection missing a row. Publishing first can repeat the event, and repetition is what every consumer is already built to survive. That single ordering is the whole at-least-once guarantee.
3. Preserve the only ordering on offer. Partition by aggregate_id and never publish two events for one aggregate concurrently: claim in (created_at, event_id) order and publish sequentially within an aggregate, or hash aggregate_id to a worker slot. Order across aggregates is not available at any price here, which is why the event carries aggregate_version and the full fact rather than a delta - a consumer can then discard what it has already applied without coordinating with anyone.
4. State the failover behaviour precisely, because it is the consistency-versus-availability decision in this design. A lease expires because the holder is slow, and no mechanism distinguishes that from dead, so for the length of the lease window two leaders can publish the same claimed batch. The system accepts duplicates to avoid stalling publication for every aggregate in the range whenever one worker pauses. Consumers deduplicate on (aggregate_id, aggregate_version) and drop anything at or below what they have applied.

Follow-up

• The relay is down 40 minutes and 9.6 million rows are pending. What does catch-up do to the primary, and what changes in the claim loop to survive it?
• A consumer insists it never received an event. Which single query settles whether the relay lost it, and what does each answer look like?

How would you troubleshoot a piece of equipment or a system process that is failing under load?

Medium · Technical and Problem Solving

Approach

1. Establish what changed and when, before forming any theory.
2. Pick a bisection that eliminates candidates whichever way it turns out.
3. Check the instrumentation before believing the symptom.
4. Separate the trigger from the cause; the deploy is rarely the bug.

Follow-up

• What would you look at first, and what would it rule out?
• How would you tell a cause from a coincidence here?

Suggested practice checklist

Built from the rounds and topics Intermountain Health candidates report.

Day 1 — Map the Intermountain Health loop

• Write out the reported sequence: Initial Screening Call, Technical Rounds, Final Panel 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 3 reported rounds, with the weakest marked.

Day 2 — Work C#

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

Deliverable: One timed worked example in C#.

Day 3 — Work .NET /.NET Fiddle

• Spend the session on .NET /.NET Fiddle, which Intermountain Health candidates report being tested on.
• Write one worked example in .NET /.NET Fiddle and time yourself on it.

Deliverable: One timed worked example in .NET /.NET Fiddle.

Day 4 — Work Programming problem solving / coding exercises

• Spend the session on Programming problem solving / coding exercises, which Intermountain Health candidates report being tested on.
• Write one worked example in Programming problem solving / coding exercises and time yourself on it.

Deliverable: One timed worked example in Programming problem solving / coding exercises.

Day 5 — Answer out loud: Technical and Problem Solving

• Answer aloud, timed: How would you troubleshoot a piece of equipment or a system process that is failing under load?
• Answer aloud, timed: Can you explain your process for converting an integer to a Roman numeral and vice-versa?

Deliverable: Spoken answers to 2 reported Technical and Problem Solving question(s), under time.

Day 6 — Answer out loud: Behavioral and Team Dynamics

• Answer aloud, timed: Tell us about a time you had to overcome a significant difficulty while working on a project.
• Answer aloud, timed: How do you handle disagreements within a development team regarding architecture or implementation?

Deliverable: Spoken answers to 2 reported Behavioral and Team Dynamics question(s), under time.

Day 7 — Dry run for Intermountain Health

• Run one full mock under time, then write down the two questions you most want to ask your interviewers.

Deliverable: A completed timed mock and two questions to ask.

Behavioural preparation

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

What is your experience with C#, SQL, and JavaScript in a production environment?

Medium · Technical and Problem Solving

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 handle edge cases when building a new function or service?

Medium · Technical and Problem Solving

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 time you had to debug a complex technical issue under pressure.

Medium · Technical and Problem Solving

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 us about a time you had to overcome a significant difficulty while working on a project.

Medium · Behavioral and Team Dynamics

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 handle disagreements within a development team regarding architecture or implementation?

Medium · Behavioral and Team Dynamics

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 your experience working in a team environment where you had to rely on others to meet a deadline.

Medium · Behavioral and Team Dynamics

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 approach learning new technologies or frameworks when a project requires them?

Medium · Behavioral and Team Dynamics

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?

What do you do when you are tasked with a project that falls outside of your primary area of expertise?

Medium · Behavioral and Team Dynamics

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?